Class III Malocclusion, Anterior Crossbite and Missing Mandibular First Molars: Bite Turbos and Space Closure to Protract Lower Second Molars

Home , Anchorage (orthodontics), Crossbite, Malocclusion

JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

Abstract Diagnosis: A 32-year-old female presented with a long face (55%), maxillary retrusion (SNA 79.5º), mandibular protrusion (SNB 82.5º), retruded lips (-4.0/-3.5mm), relative lower lip protrusion, missing lower first molars (LR6, LL6), atrophic edentulous spaces, Class III buccal segments, and anterior crossbite. The Discrepancy Index (DI) was 25.

Etiology: Early loss of L6s was probably due to molar-incisal hypomineralization (MIH). Anterior crossbite is a common functional compensation after lower second deciduous molars are lost at about age 12yr.

Treatment: A passive self-ligating (PSL) appliance, posterior bite turbos, early light short Class III elastics were used to correct the anterior crossbite. The L6 extraction sites were closed with primarily Class II elastics. Active treatment time was 20 months.

Results: Closure of the atrophic L6 sites was achieved by retracting the anterior segment and protracting lower molars. No significant root resorption nor periodontal problems were noted. The patient was pleased with treatment: excellent occlusal function, improved dentofacial esthetics, and an attractive smile arc. Clinical outcomes were a cast-radiograph evaluation (CRE) of 21 and a Pink & White (P&W) dental esthetic score of 3.

Conclusions: Severe skeletal malocclusion was corrected in 20 months with a full-fixed PSL appliance, posterior bite turbos, intermaxillary elastics, and space closure mechanics. (J Digital Orthod 2019;56:48-63)

Key words: Missing first molar, mesially tipped molar, atrophic edentulous ridge, anterior crossbite, passive self-ligating brackets, Class III elastics

Introduction Many patients with a skeletal Class III malocclusion view surgery as the only viable option. However, that is an over treatment for patients with a good profile, near Class I molar relationship, and/or an anterior functional shift. It is essential to consider the etiology and differentially diagnose the malocclusion before formulating

a treatment plan. If a centric relation (CR) to centric occlusion (CO) discrepancy exists, the problem is best 1 classified as a pseudo Class III malocclusion. Pseudo Class III patients who have an orthognathic profile in RC usually have a good prognosis for conservative treatment.

48 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

Dr. Ashley Huang, Lecturer, Beethoven Orthodontic Course (Left) Dr. Angle Lee, Editor, Journal of Digital Orthodontics (Center left) Dr. Chris H. Chang, President, Beethoven Orthodontic Center Publisher, Journal of Digital Orthodontics (Center Right) Dr. W. Eugene Roberts, Editor-in-chief, Journal of Digital Orthodontics (Right)

█ Fig. 1: Pre-treatment facial and intraoral photographs in CO

█ Fig. 2 : Functional assessment of mandible movement: intraoral photographs in CR

49 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

Diagnosis and Etiology evaluation confirmed the skeletal Class III (ANB -3˚) as previously described (Fig. 4; Table 1), but the A 32-year-old woman sought orthodontic evaluation excessive SNB angle was partially due to the C -C for missing teeth, poor dentofacial esthetics, and O R discrepancy. The TMJ radiographs (Fig. 6) showed a protrusive lower lip (Figs. 1-3). Radiographic symmetric unremarkable morphology and there examination included a lateral cephalometric film, were no signs or symptoms of TMJ dysfunction. The panoramic radiograph, and a temporomandibular American Board of Orthodontics (ABO) discrepancy (TMJ) joint series (Figs. 4-6). Cephalometric analysis index (DI) was 25 points,5 as shown in the worksheet revealed a long face, retrusive maxilla, and protrusive at the end of this report. mandible (Table 1). No contributing medical history was reported, but isolated loss of permanent first molars is usually due to a medically-related dental Treatment Objectives developmental problem in the toddler years: molar- 2 The treatment objectives were: (1) extract the incisor hypomineralization (MIH). In adults, closing hopeless lower left first molar residual root; (2) edentulous L6 spaces is challenging because of associated malocclusion, atrophic knife-edge ridge, and anchorage requirements.3-5 An anterior CEPHALOMETRIC SUMMARY crossbite may be associated with MIH, but it can be SKELETAL ANALYSIS a fortunate occurrence that increases anchorage for PRE-Tx POST-Tx DIFF. L7 protraction.3 SNA˚ (82º) 79.5˚ 79.5˚ 0˚ SNB˚ (80º) 82.5˚ 83˚ 0.5˚ Facial evaluation showed symmetrical structures, ANB˚ (2º) -3˚ -2.5˚ 0.5˚ a concave profile, retrusive lips to the E-Line, but a SN-MP˚ (32º) 35˚ 36˚ 1˚ relative protrusion of the lower lip. An unattractive FMA˚ (25º) 27˚ 28.5˚ 1.5˚ reverse smile arc was evident while smiling. The DENTAL ANALYSIS panoramic radiograph (Fig. 5) reveled missing U1 To NA mm (4 mm) 2 mm 2.5 mm 0.5 mm L6s and U8s bilaterally, retained root tip in the U1 To SN˚ (110º) 103˚ 106˚ 3˚ LR6 area, and mesial tipping of the L7s. Intraoral L1 To NB mm (4 mm) 0 mm -1 mm 1 mm examination showed missing teeth (UR8, UL8, LR6, L1 To MP˚ (90º) 77˚ 72˚ 5˚ and LL6), residual root tip in the area of the LL6, FACIAL ANALYSIS anterior crossbite of all four maxillary incisors, E-LINE UL (-1 mm) -4 mm -4 mm 0 mm buccal crossbite of the UL7, maxillary dental midline E-LINE LL (0 mm) -3.5 mm -1.5 mm 2 mm coincident with the facial midline, mandibular dental %FH: Na-ANS-Gn (53%) 55% 55.2% 0.2% midline 1mm to the left, and a C -C discrepancy O R Convexity: G-Sn-Pg’ (anterior functional shift) from an initial edge-to-edge (13º) 2˚ 1.5˚ 0.5°

position (Figs. 1-3). Pre-treatment cephalometric ██ Table 1: Cephalometric summary

50 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

█ Fig. 6: Pre-treatment TMJ radiographic series from left to right are: closed right, open right, closed left, and open left.

correct the anterior crossbite by opening the bite and retracting the lower anterior segment, (3) █ Fig. 3: Pre-treatment dental models (casts) protract the mandibular molars to close space, and (4) correct the maxillary anterior smile arc.

Treatment Alternatives Uprighting the L7s and leaving the space for implant-supported crowns was considered. That option may decrease treatment time, but it was more expensive and invasive. Also, the buccolingual width of the atrophic edentulous ridges required augmentation bone grafts. After carefully considering the pros and cons for each option, the patient selected orthodontic space closure.

█ Fig. 4: Pre-treatment lateral cephalometric radiograph Treatment Progress The patient was referred for removal of the residual LL6 root, and one month later, Damon Q® passive self-ligating (PSL) 0.022-in brackets (Ormco, Glendora, CA) were bonded on all permanent teeth. All elastics, archwires and auxiliaries were produced by the same manufacturer. Standard torque brackets were used on all teeth except: 1. low torque brackets

█ Fig. 5: Pre-treatment panoramic radiograph on the maxillary incisors, 2. low torque brackets

51 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

bonded up-side-down (to express high torque) on were effective for unlocking the interdigitation the mandibular incisors, and 3. high torque brackets and facilitating overjet and overbite correction. In on L3s. Archwire materials were copper nickel- the 4th month of treatment, a positive overjet was titanium (CuNiTi), titanium molybdenum alloy achieved and the bite turbos were removed (Fig. 8). (TMA), and stainless steel (SS). The maxillary archwire To enhance space closure efficiency and to control sequence was: 0.014-in CuNiTi, 0.014x0.025-in iatrogenic rotation, four lingual buttons were CuNiTi, 0.017x0.025-in TMA, and 0.016x0.025-in SS. bonded on the lower first premolars and the second The corresponding lower arch sequence was 0.014- molars. A sequence of 0.016x0.025-in Pre-Q NiTi and in CuNiTi, 0.014x0.025-in CuNiTi, 0.016x0.025-in 0.019x0.025-in Pre-Q NiTi wires were installed in the pre-Q NiTi (20º of lingual root torque in the anterior lower arch in the 4th and 6th months respectively, segment), 0.019x0.025-in pre-Q NiTi, and 0.016x0.025- to increase incisors torque. In the 8th month, Class in SS. In the first month of active treatment, posterior II elastics (Bear 1/4-in, 4.5-oz) were applied bilaterally bite turbos were constructed with Fuji II type II from the maxillary canines to the mandibular 2nd glass ionomer cement (GC America, Alsip IL) on the molars for 3 months to complete the A-P correction occlusal surfaces of the mandibular second molars. and promote smile arc development (Fig. 9). Fifteen The patient was instructed to wear the short Class III degree root lingual third order bends in 0.016x0.025- elastics (Quail 3/16-in, 2oz) from the upper first molars in SS archwires were applied to mandibular incisors to the lower first premolars bilaterally, to correct in the 9th month and to the maxillary incisors in the anterior crossbite (Fig. 7). Bilateral bite turbos the 15th month (Figs. 10 and 11). In the 12th month,

█ Fig. 7: In the 1st month of the treatment, the 0.014-in CuNiTi archwires engaged in all dentition of both arches. The anterior crossbite was corrected with bite turbos (blue circles), alignment of the maxillary anterior segment, and 2-oz Class III elastics (blue lines). Class III elastics provide horizontal and vertical forces to facilitate early correction of anterior crossbite.

52 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

█ Fig. 8: In the 4th month, anterior crossbite was corrected. The maxillary archwire was changed to 0.014x0.025-in CuNiTi, and the mandibular archwire was changed to 0.016x0.025-in Pre-Q NiTi.

█ Fig. 9: In the 9th month, maxillary and mandibular archwires were changed to 0.016x0.025-in SS. Class II elastics (blue lines) were applied for A-P correction, and to prevent uprighting of the lower anterior teeth during space closure.

1M 4M 9M

14 CuNiTi 14x25 CuNiTi 16x25 SS 12M 19M 20M

16x25 SS 16x25 SS 16x25 SS

█ Fig. 10: Maxillary arch form was corrected from one (1M) to twenty (20M) months with the archwire sequence as shown. In the 9th month of treatment, third order bends applied +15 degrees of lingual root torque on maxillary incisors.

53 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

14 CuNiTi 16x25 Pre-Q 16x25 SS

1M 4M 9M

16x25 SS 16x25 Pre-Q

12M 19M 20M

█ Fig. 11: In the 1st month of the treatment (1M), posterior bite turbos were bonded on the occlusal surfaces of the mandibular second molars. In the 4th month of treatment (4M), buttons were bonded on the lingual surfaces of the mandibular first premolars and second molars. Power chains were applied on the buccal and lingual surfaces from 9-19mo (9M-19M) to close the lower posterior spaces. In the 12th month, the extraction spaces were closed. Third order bends were placed in the 15th month to deliver +15 degrees of lingual root torque to the mandible incisors. By nineteen months (19M) the correction was complete and the fixed appliances were removed at twenty months (20M).

the extraction spaces were closed. Brackets were height and retraction of the lower anterior segment repositioned based on a progress panoramic (Fig. 12). The maxillary anterior segment has well radiograph. Inter-proximal reduction (IPR) of the aligned with a pleasing smile arc.6 Dental midlines mandibular central incisors was performed to correct were aligned on the facial midline, and normal the dark interproximal triangles, and to reduce arch- overbite and overjet were achieved (Fig. 13). The post- length to permit an ideal overjet correction. Fixed treatment panoramic and cephalometric films (Figs. appliances were removed after 19 months of active 14 and 15) revealed harmonious axial inclinations in treatment. Two fixed retainers were bonded buccally the buccal segments with all interproximal spaces between the mandibular second premolars and the closed. An unusual external apical root resorption second molars to maintain space closure. Retention was noted. The cephalometric analysis revealed was provided with maxillary and mandibular clear that the upper incisor to SN angle was increased overlay retainers. 5 degrees, and the SNB angle was decreased from 84 to 81 degrees (Table 1). Superimposition of cephalometric tracings from before and after Treatment Results treatment showed that the mandibular anterior Facial esthetics with a more harmonious facial profile segment was retracted about 5mm, and was were achieved by a modest increase in lower facial lingually inclined about 4 degrees. Mandibular

54 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

█ Fig. 12: Post-treatment facial and intraoral photographs show two fixed retainers (blue arrows) bonded on the buccal surfaces of the mandibular second premolars and the second molars.

second and third molars were protracted, uprighted, and extruded, which was associated with ~1 degree clockwise rotation of the mandible (Fig. 16). The patient was well satisfied with the treatment results. The ABO cast radiograph evaluation (CRE) score was 21 points,7 as shown in the worksheet at the end of this report. The major alignment discrepancies were marginal ridges and buccolingual inclination of the molars. Substituting mandibular third molars for second molars may be challenging because of morphologic variabilities of the crown. The Pink and White (P&W) esthetic score was 3 points,8 which █ Fig. 13: Post-treatment dental models (casts)

55 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

█ Fig. 14: Post-treatment lateral cephalometric radiograph █ Fig. 15: Post-treatment panoramic radiograph

█ Fig. 16: Superimposed cephalometric tracings showing dentofacial changes after 19 months of treatment (red) compared to pre-treatment (black). The protrusive lower lip was corrected, resulting in a more balanced facial profile. Maxillary incisor axial inclination was increased 5˚ and mandibular incisors were retracted ~5mm. The mandibular second molar(s) was protracted and substituted for the missing 1st molar(s).

56 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

reflected gingival prominence on the UR1. Attrition on the incisal edges of the 4 maxillary incisors was due to occlusal interference before orthodontic treatment. Two-year-follow-up intraoral photographs showed stable occlusion and a harmonious curvature of gingival margins (Fig. 17).

Discussion Differential diagnosis of skeletal Class III malocclusion with an anterior crossbite is essential for formulating an efficient treatment plan. Treatment options are orthodontic treatment with or without orthognathic

surgery. Class III patients with an acceptable profile and near Class I molar relationship in CR are good

candidates for conservative orthodontic treatment particularly if there is a pretreatment CR → CO functional 1 shift. If the latter is present, the diagnosis is pseudo Class III malocclusion. In CR the present patient had

a straight facial profile, Class I molar relationship, and an anterior functional shift to achieve CO. These

██ Table 2: Archwire sequence chart

57 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

█ Fig. 17: 2-year-follow-up intraoral photographs

diagnostic features suggested a good response to dentoalveolar treatment. Posterior bite turbos on L7s and light force Class III elastics facilitated the anterior crossbite correction and retracted the lower premolars. After only 3 months of active treatment, a positive overjet was achieved.

Upper incisors flare when crowding is corrected without extraction or interproximal reduction, and the problem is enhanced with Class III elastics. █ Fig. 18: Conservative correction of anterior crossbite with Class III elastics To control maxillary incisal flaring, low torque (blue line) tends to flare maxillary incisors and tip mandibular brackets (+7 and +3) are indicated for central and incisors lingually (yellow arrows). Decreased torque is required in upper incisor brackets (green arrow) and increased torque in lower lateral incisors, respectively. Class III elastics tip incisor brackets (red arrow). The posterior bite turbos (purple circle) unlock the interdigitation to permit retraction of the lower anterior lower incisors lingually, so high torque brackets segment. are indicated. There are no high torque brackets available for lower incisors, so low torque brackets

58 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

are bonded up-side-down to achieve the desired torque (Fig. 18).

Missing mandibular first molar is common among adult orthodontic patients.1-3 Since the L6s are lost early due to MIH,2 the L7s tip mesially into the space, and the edentulous ridge becomes atrophic. Stepovich9 found that L6 extraction sites can be closed if the edentulous ridge is 6 mm or less in mesiodistal length and ~7mm in buccolingual width. For the present patient, the mesiodistal dimensions were 7mm on the left, 8mm on the right, and the █ Fig. 19: Closing space with sliding mechanics (yellow arrows) on a heavy SS buccolingual alveolar bone widths were >8mm rectangular wire is facilitated by balancing lingual (green arrows) on both sides. After 19 months of treatment, the and buccal moments (red arrows) to avoid the tendency for mesial and lingual tipping and iatrogenic rotation of the second molars. extraction sites closed and the axial inclination in the buccal segments were WNL (Fig. 15). with sliding mechanics on a heavy SS rectangular wire is facilitated by balancing lingual and buccal Extra-oral devices such as a facemask are relatively forces to prevent iatrogenic rotation (Fig. 19). Space inefficient, but retromolar endosseous implants re-opening of the mandibular first molar extraction are effective indirect anchorage for protracting sites may occur after appliances are removed. Fixed lower molars.10 Miniscrews are used for anchorage retention for mandibular posterior space closure is reinforcement,11-13 but there may be problems indicated.17 with adequate sites and screw movement during molar protraction.14,15 Conservative space closure is effective when intermaxillary force is used and Conclusions retraction of the lower anterior segment is desirable 1. Differential diagnosis of Class III malocclusion with (Figs. 7-16). Protraction of lower molars with intra- anterior crossbite requires an evaluation of the arch mechanics results in retraction of the lower facial profile, molar classification, and functional anterior segment.16 For the present patient, the shift. Differentiating between the true and the extraction space was used to align the teeth and pseudo Class III malocclusions is essential when correct the negative overjet, so there was no need predicting prognosis and also for preventing over- for anchorage reinforcement. treatment.

2. Closing mandibular extraction sites controls Large dimension rectangular wires help control axial treatment costs by eliminating the need for inclinations during space closure. Closing spaces

59 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

surgical and restorative procedures. However, extraction treatment in Class II Division 1 using C-orthodontic mini-implants. Angle orthod 2007;77:155–66. control of the mechanics for tooth movement is 13. Kravitz ND. Mandibular molar protraction with temporary also important. Dividing buccal and lingual force anchorage devices. J Clin orthod 2008;42:351–5. on a heavy archwire prevents rotation as well as 14. Chhibber A, Upadhyay M. Anchorage reinforcement mesial and/or lingual tilting of the second molar. with a fixed functional appliance during protraction of the mandibular second molars into the first molar extraction sites. Am J Orthod Dentofac Orthop 2015;148(1):165–73. Reference 15. Hom BM, Turley PK. The effects of space closure of the mandibular first molar area in adults. Am J Orthod 1. Ngan P, Hu AM, Fields HW. Treatment of Class III problems 1984;85(6):457–69. begins with differential diagnosis of anterior crossbites. Am 16. De Oliveira Ruellas AC, Baratieri C, Roma MB, Angle Class III Acad Pediatr Dent 1997;19:386–95. malocclusion treated with mandibular first molar extractions. 2. S ch n e i d e r PM, Si lva M. E n d e mi c m o l a r i n ci s or Am J Orthod Dentofac Orthod 2012;142(3):384–92. hypomineralization: a pandemic problem that requires 17. Chiu GSC, Chang CCH, Roberts WE. Interdisciplinary monitoring by the entire health care community. Curr treatment for a compensated Class II partially edentulous Osteoporos Rep 2018;16(3):283-288. malocclusion: orthodontic creation of a posterior implant site. 3. Lu S-W, Chang C, Roberts WE. Asymmetric crowded Class Am J Orthod Dentofacial Orthop 2018;153(3):422-435. II with missing first molars: space closure or implants? Int J Ortho Implantol 2015;40:18-41. 4. Chang MJ, Kuo PJ, Lin JJ, Roberts WE. Mutilated Class III malocclusion with anterior crossbite and autotransplantation of two molars. J Digital Orthod 2019;54:4-23. 5. Cangialosi TJ, Riolo ML, Owens SE Jr, et al. The ABO discrepancy index: A measure of case complexity. Am J Orthod Dentofac Orthop 2004;125:270–8. 6. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop 2001;120(2):98-111. 7. Casko JS, Vaden JL, Kokich VG, Damone J, James RD. American board of orthodontics: Objecting grading system for dental casts and panoramic radiographs. Am J Orthod Dentofacial Orthop 1998;114(5):589–99. 8. Su B. IBOI Pink & White esthetic score. Int J Orthod Implantol 2013;28:80-85. 9. Stepovich ML. A clinical study on closing edentulous spaces in the mandible. Angle Orthod 1979;49(4):227–33. 10. Roberts, WE, Nelson, CL, Goodacre, CJ. Rigid implant anchorage to close a mandibular first molar extraction site. J Clin Orthod 1994;28(12):693-704. 11. Nagaraj K, Upadhyay M, Yadav S, Sung JH. Titanium screw anchorage for protraction of mandibular second molars into first molar extraction sites. Orthod Dentofac Orthop 2008;134:583–91. 12. Chung KR, Cho JH, Kim SH, Kook YA, Cozzani M. Unusual

60 JDO 56 CASE REPORT DISCREPANCY INDEX WORKSHEETClass III Malocclusion TreatedEXAM with YEAR Mandibular 2009 First Molar Substitution JDO 56 PATIENT CHAO-YUEN CHIU CASE # 1 (Rev. 9/22/08) ABO ID# 96112 TOTAL D.I. SCORE 25

OVERJET LINGUAL POSTERIOR X-BITE Discrepancy0 mm. (edge-to-edge) Index = 1Worksheet pt. 1 Ð 3 mm. = 0 pts. 1 pt. per tooth Total = 10 DISCREPANCY3.1 Ð 5 mm. INDEX = 2WORKSHEET pts. EXAM YEAR 2009 5.1 Ð 7 mm. = 3 pts. CASE # PATIENT CHAO-YUEN CHIU BUCCAL POSTERIOR X-BITE 7.1 Ð 9 mm. 1 (Rev. = 9/22/08) 4 pts. ABO ID# 96112

T>OTAL 9 mm. D.I. SCORE = 2525 5 pts. 2 pts. per tooth Total = 02 Negative OJ (x-bite) 1 pt. per mm. per tooth = OVERJET LINGUAL POSTERIOR X-BITE CEPHALOMETRICS (See Instructions) 0 mm. (edge-to-edge) = 1 pt. Total = 5 1 pt. per tooth Total = 0 1 Ð 3 mm. = 0 pts. ANB ≥ 6¡ or ≤ -2¡ = 4 pts. 3.1 Ð 5 mm. = 2 pts. 0 5.1OVERBITE Ð 7 mm. = 3 pts. BUCCAL Each degree POSTERIOR < -2¡ X-BITEx 1 pt. = 7.1 Ð 9 mm. = 4 pts. 1 1 0 Ð 3 mm. = 0 pts. > 9 mm. = 5 pts. 3.1 Ð 5 mm. = 2 pts. 2 pts. Each per degree tooth > 6¡ Total = x 1 pt. = 2 Negative5.1 Ð 7 mm. OJ (x-bite) 1 pt. per = mm. per 3 pts. tooth = 0 Impinging (100%) = 5 pts. 8 CEPHALOMETRICSSN-MP (See Instructions) ≥ Total = 5 38¡ = 2 pts. Total = 85 ≥ ≤ ANB Each degree6¡ or > -2¡38¡ x 2 pts. = = 4 pts. OVERBITE Each ≤degree 26¡ < -2¡ x 1 pt. = = 1 pt. 0 ANTERIORÐ 3 mm. OPEN BITE = 0 pts. Each degree < 26¡ 4 x 1 pt. = 4 3.1 Ð 5 mm. = 2 pts. Each degree > 6¡ x 1 pt. = 5.10 mm.Ð 7 mm. (edge-to-edge), =1 pt. per 3tooth pts. Impingingthen 1 pt. (100%)per additional = full mm. 5 pts. per tooth SN-MP1 to MP ≥ 99¡ = 1 pt. Each ≥ 38¡ degree > 99¡ 2 x 1 pt. = = 2 pts.2 Total = 5 Total = 00 Each degree > 38¡ x 2 pts. =

LATERAL OPEN BITE ≤ 26¡ Total = = 1 pt. 8 ANTERIOR OPEN BITE 5 Each degree < 26¡ 4 x 1 pt. = 4 2 pts. per mm. per tooth OTHER 0 mm. (edge-to-edge), 1 pt. per tooth (See Instructions)

then 1 pt. per additional full mm. per tooth 1 toSupernumerary MP ≥ 99¡ teeth =x 1 pt.1 pt. = Total = 0 EachAnkylosis degree of perm.> 99¡ teeth 2 x 1 pt. =x 2 pts.2 = Total = 00 Anomalous morphology x 2 pts. = CROWDING (only one arch) Impaction (except 3rd molars) x 2 pts. = Midline discrepancy (≥3mm) @0 2 pts. = LATERAL1 Ð 3 mm. OPEN BITE = 1 pt. Total = 8 Missing teeth (except 3rd molars) 2 x 1 pts. = 2 3.1 Ð 5 mm. = 2 pts. Missing teeth, congenital x 2 pts. = 2 5.1pts. Ð per 7 mm. mm. per tooth = 4 pts. OTHER (See Instructions) Spacing (4 or more, per arch) 1 x 2 pts. = 22 > 7 mm. = 7 pts. ≥ 2 SupernumerarySpacing (Mx cent. teeth diastema 2mm) x 1@ pt. 2 pts.= = Total = 0 Tooth transposition x 2 pts. = Total = 01 Ankylosis of perm. teeth x 2 pts. = AnomalousSkeletal asymmetry morphology (nonsurgical tx) x 2@ pts. 3 pts. =2 = CROWDING Addl. treatment complexitiesrd x 2 pts. = (only one arch) Impaction (except 3 molars) 3 x 2 pts. = 6

OCCLUSION Midline discrepancy (≥3mm) @ 2 pts. = 1 Ð 3 mm. = 1 pt. Identify: Molar protraction x2 Missing teeth (except 3rd molars) x 1 pts. = 3.1Class Ð 5 Imm. to end on = = 2 0pts. pts. Missing teeth,CO/CR congenital discrepancy x 2 pts. = 5.1 Ð 7 mm. = 4 pts. End on Class II or III = 2 pts. per side pts. Spacing (4 or more, per arch) Total x 2 pts.= = 4 2 > 7 mm. = 7 pts. per side pts. 10 Full Class II or III = 4 pts. Spacing (Mx cent. diastema ≥ 2mm) @ 2 pts. = 2 Beyond Class II or III = 1 pt. per mm. pts. Tooth transposition x 2 pts. = Total = 1 additional 3 6 1 Skeletal asymmetry (nonsurgical tx) @ 3 pts. = Addl. treatment complexities x 2 pts. = Total = 0

OCCLUSION Identify: Class I to end on = 0 pts. 8 End on Class II or III = 2 pts. per side pts. Total = 4 Full Class II or III = 4 pts. per side pts. Beyond Class II or III = 1 pt. per mm. pts. additional Total = 0

61 JDO 56IBOI CASE REPORTCast-Radiograph Evaluation Occlusal Contacts Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

Patient

Cast-Radiograph Evaluation Occlusal Contacts 1

�� Alignment/Rotations Case # Patient Total Score: 21

Alignment/Rotations

3 1

1 1 1

Marginal Ridges

Occlusal Relationships Marginal Ridges

6 Occlusal Relationships

2 1 1 1 2 1 1

1 Buccolingual Inclination Interproximal1 Contacts1

Interproximal Contacts Buccolingual Inclination 0 6

1 1 1 1 1 1

Overjet Overjet Root Angulation 3 0 1 1 1

1 1

INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter INSTRUCTIONS: in the white Placebox. Mark score extracted beside eachteeth deficientwith ÒXÓ. Secondtooth and molars enter should total bescore in occlusion. for each parameter in the white box. Mark extracted teeth with ÒXÓ. Second molars should be in occlusion. 62 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56

IBOI Pink & White Esthetic Score Total Score: = 3 Total = 1. Pink Esthetic Score 1

1. M & D Papillae 0 1 2 5 5 4 6 4 2. Keratinized Gingiva 0 1 2 6 53 2 35 14 2 5 4 3. Curvature of Gingival Margin 0 1 2 6 3 14 2 53 1 2 3 14 4. Level of Gingival Margin 0 1 2 3 2 3 1 5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

1. M & D Papilla 0 1 2

2. Keratinized Gingiva 0 1 2

3. Curvature of Gingival Margin 0 1 2

4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

2. White Esthetic Score ( for Micro-esthetics ) Total = 2

1. Midline 0 1 2 . Incisor Curve 4 3 1 2 0 1 2 4 3 1 11 2 3. Axial Inclination (5°, 8°, 10°) 0 1 2 4 3 2 3 1 4 3 5 6 4. Contact Area (50%, 40%, 30%) 0 1 2 4 1 5 26 4 3 2 5 5. Tooth Proportion (1:0.8) 0 1 2 2 6 2 6. Tooth to Tooth Proportion 0 1 2

1. Midline 0 1 2

2. Incisor Curve 0 1 2

3. Axial Inclination (5°, 8°, 10°) 0 1 2

4. Contact Area (50%, 40%, 30%) 0 1 2

5. Tooth Proportion (1:0.8) 0 1 2

6. Tooth to Tooth Proportion 0 1 2